Dr Gunta Lazdane
Posted 13th Jul 2015
Dr Lazdane: That’s an almost impossible question to answer, given the size of the area covered by WHO Europe – 53 countries, stretching from the Atlantic to the Pacific, including the Russian Federation, the Baltic countries as well as those in Central Asia, in addition to Western and Central Europe. It’s a very diverse area; the biggest challenge in the UK or Italy, for example, doesn’t necessarily manifest itself in the same way in Central Asia, where maternal health is the major issue – maternal mortality is up to forty times greater than in countries with the lowest maternal mortality in Europe, although these comparisons are based on estimates, and the reliability of data is relatively poor. We are doing what we can to improve data quality, while, at the same time, working with countries to look beyond the numbers, to see the women behind the data. Here we have learned a lot from work in the UK, and WHO Europe is assisting countries to assess mortality on a case-by-case basis, learning from the confidential enquiry system pioneered in the UK. Working with UNFPA, we are also encouraging countries to look at “near misses”, as the women themselves can be part of this assessment exercise. A 2013 EU Perinatal Report emphasised the need to examine and learn from each death.
In Denmark, on the other hand, where the profile is similar to other Scandinavian countries, the biggest sexual health challenge is probably related to migrant sexual health, in particular the critical need for sex education for migrants and refugees, who are often from different cultures, and lack access to timely SRH services of good quality. This issue needs to be tackled with care, but also with a sense of urgency.
As you probably know, within the WHO Europe Office, HIV/AIDS is a separate division to mine. In my work the prevention of maternal to child transmission of HIV is the central priority. Within Europe as a whole the epidemic is becoming more heterosexual. I would say that we have a long way to go when it comes to integrating sexual health and HIV policies and programmes. Certainly in my work in some Central Asian countries, there are people who are well informed about HIV/AIDS, but who know next to nothing about contraception.
The Strategic Framework for WHO Europe Region is Health 2020, was approved by 53 countries in 2012, and has as one of its key objectives to address health inequalities and achieve greater social justice and inclusion for vulnerable people. It advocates a “whole government” approach, within which ministries of health are encouraged to work with ministries of education and others to ensure that the multifaceted aspects of sexual and reproductive health programming are recognised. Within this context, we are working with civil society organisations on a European Sexual and Reproductive Health Action Plan, which will have specific goals and indicators, and will be presented in 2016 for approval.
Migrant sexual health is a key issue, not just in Western and Northern Europe. For example, in several Central Asian countries, migrant workers flow in and out, and there is often quite a lot of internal migration, all of which leads to problems with accessing information, education and services related to sexual and reproductive health.
Sexual violence is another important issue; for example, at the moment there is no bride kidnapping in Sweden, or female genital mutilation (FGM) in Central Asia. But FGM requires additional attention in Malta, Belgium and other countries of the Region.
The new Global STI Strategy is almost finalised; it will be launched in 2016. In Europe, STIs are no longer primarily a problem of young people; they are increasingly affecting people in older age groups. Among STIs, we are encountering increasing antibiotic resistance to gonorrhoea, and I would certainly say that we are not investing enough in tackling these issues.
We’ve done quite a lot over the last five years. Sexuality education is really important, the main goal of which is to empower young people to make informed choices for themselves. There is a certain degree of “political blindness” about sexuality education. We have published standards, covering best practice for sexuality education; it’s a publication we’ve received the most compliments for, but also the one which generated the most discussion, presented the most difficulties, and was the most controversial.
EU governing bodies have been resistant to discussing sexual health including sexuality education, but many Members of the EU Parliament are organising meetings and inviting WHO to discuss the existing challenges in the area with them. The situation is improving slowly in Central Europe; again this is an area which needs the “whole government” approach, with the ministries of health and education working together. It’s a slow process, but we’re seeing some progress.
Focus on education. Not just in schools, but everywhere it’s needed to make sure that every citizen has access to the evidence-based information, education and services of high quality they need to be able to make full, free and informed choices about their sexual health. Sexual and reproductive health needs to be seen as a long-term investment. In some ways we have come full circle; the abortion situation in the region is getting worse. It continues to be highly politicised, and barriers to women’s ability to make their own choices remain persistently in place. Analysis of media coverage of abortion over a sustained period of time has shown that the number of abortion-related stories correlated directly with proximity to political elections. Abortion has to be seen as a political problem; it has been solved medically. And we know that, even if we do everything possible to prevent unplanned pregnancy, there will always be a need for abortion. It is a topic that retains its emotional charge, and in some countries where nationalist movements are becoming stronger, the abortion issue can become highly politicised.
Concerns about low birth rates in some European countries can make sexual health work more difficult; family planning doctors are sometimes blamed for promoting or being partly responsible for low fertility. Practitioners need to become more adept at emphasising the role of sexual health in protecting fertility, through the prevention, diagnosis and treatment of STIs, for example. It is important that civil society becomes involved in supporting WHO and other policy documents that encourage the provision of high quality sexual and reproductive health information, education, and services (including STI prevention, diagnosis and treatment, a full range of contraceptive options), and in holding governments accountable for both resourcing and implementing such policies.
Monitoring our strategies could be better; it isn’t an easy area to work in, because governments tend to think that sexual and reproductive health isn’t a priority – people aren’t dying in the 21st century in Europe from causes related primarily to sexual and reproductive health, so health funding priorities tend to be with noncommunicable diseases. But sexual health is life enhancing; if we take the WHO definition of health embracing well-being, and not just the absence of disease or infirmity, then sexual health is an important if not essential element. We have to be vigilant about over-medicalisation in our profession – it might be easier to do ten ultrasounds on one pregnancy than facilitate a good counselling session, but does it make sense and is it necessary?
More than one message, I know, but I’d like to leave you with a final thought. Sexual and reproductive health practitioners must monitor the quality of the information accessed, especially by young people, on health apps. We know of instances where health visitors have given wrong information based on health apps. That’s why my one message started with education; we all have a responsibility to ensure that, when people do access information, it’s accurate, unbiased, and fit to form the basis on which they can make full, free, informed and often life-changing decisions.
The eFeature interview was conducted by Karen Newman on behalf of MEDFASH.
The content of all eFeatures represents the views and opinions of the authors. MEDFASH does not necessarily share or endorse the views expressed within them.
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